BILL GATES Co-chair Bill & Melinda Gates Foundation

RAY CHAMBERS United Nations Secretary-General's Special Envoy for Financing the Health Millennium Development Goals and for Malaria

Photo by Esther Havens / Malaria No More From Aspiration to Action | 4

Table of Foreword 5

Contents Key Messages 9

Overview 13

Why do we need to end malaria? 15

What will it take to end malaria? 17

I. New Strategies 31

II. New Tools 39

III. New Financing 43

Conclusion 51

Appendices 53 5 | From Aspiration to Action Foreword

In the year 2000, the world committed to “halt and reverse” the tide of malaria as a key element of the Millennium Development Goals. Fifteen years later, we have achieved that goal and more. An estimated 6.2 million lives have been saved from malaria since the year 2000, and the rate of deaths from malaria has been reduced by an astonishing 58% globally.

Based on this success, we have an opportunity to do 2030. Work to achieve that goal is under way and an economic progress and help to ensure that all what was once thought impossible: to end this disease Asia Pacific Malaria Elimination Roadmap for action children have the opportunity to lead the healthy and for everyone, everywhere on the planet, forever. has been drafted for consideration at the November productive lives to which they are entitled. 2015 East Asia Summit. As co-chair of UN Secretary General Ban Ki-Moon’s Success will demand the dedication of all stakeholders, High Level Panel of Eminent Persons on the Post- In line with this goal, I welcome the bold vision and it will require that afected countries strengthen 2015 Development Agenda I applaud the initiative for global malaria eradication contained in From their health systems, enhance their disease behind the call for action and the vision that gives Aspiration to Action: What will it Take to End Malaria? As surveillance capabilities, and their capacity to treat and us of our potential as a global family to eliminate we all know, a malaria-free world can only be achieved care for those afected—in short we need to prevent malaria. through careful planning, continuous innovation, hard new malaria, quickly detect infection, and respond work, and active leadership pointing the way, calling rapidly and appropriately. Ultimately leaders of malaria-afected countries for action and providing necessary resources. The are accountable for keeping their citizens safe from global community must move forward together fully The most precious resource of any nation is its malaria and accelerating the elimination of a disease committed to working for achievement of national children, and leaders in all countries are focused on that claims the lives of more than 500,000 people and regional plans well supported by the new tools, the goal of creating a future where no child sufers each year. I am gratified that in my own region with strategies, and the financing required to accelerate or dies unnecessarily. That means we must eliminate the support of Asia Pacific Leaders Malaria Alliance elimination of malaria. malaria. I thank the authors of “From Aspiration (APLMA), we have set ambitious elimination goals. to Action” for showing us so clearly that this is In November 2014, at the East Asia Summit, 18 For all our progress, more than half of the world’s something we can and must do. countries gathered at the East Asia Summit joined children still live at risk of malaria. Eliminating in pledging to eliminate the disease in our region by malaria will remove a key barrier to social and Jakarta, August 2015

Dr. Susilo Bambang Yudhoyono President of Indonesia (2004-2014) Co-Chair of the Secretary General’s High Level Panel of Eminent Persons on the Post-2015 Development Agenda From Aspiration to Action | 8

Foreword

The global community has proven that we can overcome the most formidable of challenges through innovative partnerships and ambitious-yet-achievable targets. An outstanding example is the unprecedented success we have achieved against the scourge of malaria. Since the adoption of the Millennium Development Goals in 2000, we have saved more than 6 million lives globally and reduced malaria deaths in children under five by nearly 70% in Africa. We now stand positioned to accomplish what has evaded prior generations—ending malaria once and for all.

From Aspiration to Action: What Will It Take to End impede on the prosperity of our communities, taking Malaria? recognizes this unique opportunity and lays huge human and economic tolls across the continent. out the key elements to achieve a world free of malaria: country and regional strategies, maintaining political In January 2015, Africa’s Heads of State and leadership, strong multi-sectorial partnerships, Government convened at the African Union in Addis new investments and financing strategies, and the Ababa, Ethiopia and pledged to work together to development of innovative prevention and diagnostic achieve a malaria-free Africa within a generation. tools. All are key in driving this necessary work Through the African Leaders Malaria Alliance forward. We embrace the opportunity to contribute (ALMA), a coalition of 49 African heads of state, the to this efort, and we commit to seeing this bold aim continent’s malaria-afected countries have adopted of global eradication achieved. a rigorous elimination scorecard that will allow them to track their progress toward achieving efective In the past 15 years, Sub-Saharan Africa has made intervention coverage and significant reductions in historic progress in turning the tide against malaria. parasite burden. This scorecard is already helping Incidence of the disease has declined by more than eight nations in southern Africa scale up their eforts one-third, and deaths have fallen by 58% among to achieve malaria elimination by 2020. all age groups. Thanks to strong collaboration between African governments and the international We must seek the end of malaria—there is no other donors, the percentage of Africans who have access way forward. The time is now to make the vision of to afordable treatment and diagnosis has grown From Aspiration to Action become reality. dramatically. Yet, the burden of malaria continues to

His Excellency Jakaya Mrisho Kikwete President of the United Republic of Tanzania Founding Chair of the African Leaders Malaria Alliance AWA Champion for Malaria Prevention and Control 9 | From Aspiration to Action From Aspiration to Action | 10

ERADICATION WILL PRODUCE ENORMOUS HEALTH Key Messages AND ECONOMIC BENEFITS. Leading economists have identified the fight THE WORLD HAS MADE UNPRECEDENTED PROGRESS against malaria as one of the “best buys” in global AGAINST MALARIA IN THE PAST 15 YEARS. development, estimating that a 50-percent reduction in Since 2000, global malaria deaths have fallen 58 global malaria incidence could produce $36 in percent, and half of the world’s nations are now economic benefits for every $1 invested.4 A new malaria-free.1 Gains against malaria account for 20 analysis also indicates that malaria eradication could percent of the total progress that the world has made deliver more than $2 trillion (U.S.) in economic benefits in reducing preventable child and maternal mortality and save an estimated 11 million lives. under the Millennium Development Goals (MDGs).2

ERADICATION IN THE 21ST CENTURY WILL DIFFER THE LEADERS OF THE WORLD’S MALARIA- DRAMATICALLY FROM PAST EFFORTS. AFFECTED COUNTRIES HAVE MADE A STRONG Malaria eradication will not rely on the 20th-century POLITICAL COMMITMENT TO MALARIA ELIMINATION. model of a large-scale global campaign funded and Progress against malaria has convinced Asian and organized by foreign donors and focused on a single African leaders to commit their regions to malaria intervention. Its success today will depend on the degree elimination within a generation.3 The World Health to which countries integrate malaria surveillance, Organization’s (WHO) Global Technical Strategy transmission interruption, and treatment programs for Malaria (GTS) and the Roll Back Malaria (RBM) into their national health systems. Eradication in Partnership’s Action and Investment to defeat Malaria the 21st century will adapt to emerging challenges (AIM) have embraced the goal of a “world free of by using data to plan interventions and R&D to stay malaria.” ahead of drug and insecticide resistance. It will also use operational research to identify the most efcient and efective approaches for deploying new tools and ERADICATION IS THE ONLY SUSTAINABLE SOLUTION strategies as they become available. TO MALARIA. The alternative to eradication—controlling the disease forever without eliminating it—is operationally and IN CONTRAST TO OTHER ERADICATION EFFORTS, politically untenable. It would require indefinite ENDING MALARIA WILL NOT BE A HIGH-RISK, ALL- investment in malaria control and the development OR-NOTHING PROPOSITION. and delivery of an endless succession of treatment and More than 100 United Nations member states have prevention technologies to stay ahead of resistance in successfully eliminated malaria, and history has shown both parasites and mosquitoes. It will be impossible to that elimination “sticks” once it has been achieved. This maintain strong political commitment unless we can means that regions that have eliminated the disease To achieve the aspiration define a clear end point—and history has shown that will not need to maintain costly and intensive malaria of a malaria-free world, we unless countries reduce their case burdens to zero, we surveillance eforts and can use more general infectious will see resurgence on a massive scale. disease surveillance to avoid resurgence. It also means must start taking action now. that countries and regions will be able to set their own schedules for elimination once they are confident that 1 United Nations, The Millennium Development Goals Report 2015 (New York: UN, 2015). the necessary tools, strategies, and financing are in 2 World Health Organization, World Malaria Report 2014 (Geneva: WHO, 2014). place. 3 Asia Pacific Leaders Malaria Alliance Secretariat, ‘East Asia Summit Adopts Unprecedented Regional Malaria Goal’. November 14, 2014. Web. African Union, ‘High-level Dialogue on Defeating Malaria in Africa by 2030, 4 Copenhagen Consensus Center, ‘Health - Infectious Diseases’. 2015. Web. Addis Ababa, Ethiopia’. April 25, 2015. Web.

Photo by Esther Havens / Malaria No More 11 | From Aspiration to Action From Aspiration to Action | 12

AFFECTED COUNTRIES AND REGIONS WILL PLAY A WE MUST TAKE ACTION IN THE NEXT FIVE YEARS TO PUT DECISIVE ROLE IN LEADING AND FINANCING MALARIA THE WORLD ON THE PATH TO ERADICATION. ELIMINATION EFFORTS. Malaria eradication is a highly ambitious goal that will require Traditional donors currently provide most of the funding for bold thinking and unwavering commitment. Like launching a the fight against malaria, but domestic financing is growing rocket, if your trajectory is of at the beginning, you have little and it will be the key factor in funding ambitious elimination chance of reaching your ultimate destination. Success during eforts over the next two decades. The success of eradica- the next 5 years is crucial, even the next 36 months, is crucial tion will be largely built on a series of successful nation- to putting the world on a trajectory to achieve eradication al and sub-regional elimination programs, driving global in our lifetimes. Key milestones in the above areas must be eradication from the bottom up. met by 2020–beginning with achieving or exceeding the 40 percent decline in malaria morbidity and mortality called for in the WHO Global Technical Strategy–to inspire the world to WE NEED NEW STRATEGIES, NEW TOOLS, AND commit to and pursue malaria eradication with confidence NEW FINANCING APPROACHES TO ACHIEVE A and vigor. Ultimately, this commitment should be reflected MALARIA-FREE WORLD. in a World Health Assembly resolution supporting malaria eradication by a specific end date. To achieve the aspiration NEW STRATEGIES: We need to adopt better approaches to of a malaria-free world, we must start taking action now. surveillance that will both identify key sources and pathways of malaria transmission and focus diagnosis, treatment, and prevention resources where they can be most efective in ac- celerating parasite elimination and saving lives. New strate- Success during the next three to five gies will also help to identify the most efcient ways to de- years is crucial to putting the world ploy malaria interventions, stretching the life-saving impact on a trajectory to achieve eradication of every dollar invested in malaria. in our lifetimes.

NEW TOOLS: The product development pipeline for malaria has never been stronger, with promising new tools that will revolutionize how we detect, treat, and prevent malaria. We can accelerate eradication by increasing investment in R&D and clearing regulatory and market hurdles to the rapid de- ployment of new tools.

NEW FINANCING: We need to double malaria funding by 2025 to accelerate progress toward a malaria-free world. This will require sustained support from current donors and significantly increased domestic investment from afected countries, facilitated in part by concessionary lending and novel financing approaches.

Photo by Esther Havens / Malaria No More 13 | From Aspiration to Action

Overview

From Aspiration to Action: What Will It Take to End Malaria? seeks to spark a serious conversation about what it will take to eradicate malaria within a generation. It is addressed to the key decision-makers—affected country leaders, donor country leaders, multinational institutions, and others—who will need to organize, finance, and implement the effort.

To clarify the hard choices and clear commitments From Aspiration to Action focuses particularly on these key stakeholders must make to put the world the key actions that must be taken in the next five years on the path to eradication, the document works back to create the necessary confidence and consensus from a theoretical end date of 2040. This date was for a World Health Assembly commitment to chosen as a reasonable assumption that balances malaria eradication. This should include a robust stated country ambitions, anticipated technology debate among stakeholders as to the necessary advances, and implementation realities. It is used preconditions for eradication. The technical elements to anchor the original epidemiological and financial of these discussions will need to be led by the Global modeling that is a part of this analysis. 2040 should Malaria Program of the World Health Organization not be misconstrued as a firm policy proposal. The (WHO) in partnership with regional leaders, and they ultimate target date for malaria eradication must should be built on the solid foundations laid by the be the result of a consultative process with global WHO’s Global Technical Strategy for Malaria5 and leaders and technical experts, and must be reflected Roll Back Malaria (RBM) Partnership’s Action and in a renewed World Health Assembly commitment. Investment to defeat Malaria, 2016-2030.6

5 World Health Organization, Global Technical Strategy for Malaria 2016-2030 (Geneva: WHO, 2015). 6 Roll Back Malaria, Action and Investment to defeat Malaria 2016-2030 (Geneva: WHO, 2015).

Photo by Malaria No More / John Rae 2008 15 | From Aspiraton to Action From Aspiration to Action | 16 Why do we need to end malaria? Photo by Esther Havens / Malaria No More A little more than a century ago, malaria was a leading cause of death in nearly every nation on From Aspiration to Action: What Will It Take to End Malaria? earth. Then scientists discovered that malaria is caused by a parasite and they determined that seeks to initiate this dialogue. It does so by starting to outline the conditions that must be met to secure a this parasite is transmitted between humans by mosquitoes. These insights were applied to the renewed World Health Assembly (WHA) commitment to development of effective treatment and prevention tools—and by 2000, nearly half of the United malaria eradication, as well as the time and resources that Nations’ member states had eliminated the disease within their borders. will be required to end malaria forever. It identifies 2020 as a reasonable target date to secure renewed WHA support, In the past 15 years, the pace of progress against malaria malaria parasite, and nearly 500,000 children still die from and it identifies 2040 as an ambitious-but-attainable target reasonable—indeed essential—to avoid repeat- has only accelerated. The number of children who die this preventable disease each year—the equivalent of one date to achieve global malaria eradication. ing past mistakes. This document addresses the from malaria has fallen by more than 50 percent,7 and the child every minute.11 While half of the world’s countries doubts that some experts have raised about the fea- United Nations estimates that 6.2 million lives have been have eliminated malaria, a situation where the other half’s These timelines are intended to provoke vigorous debate. sibility of malaria eradication by underscoring the saved by malaria interventions between 2000 and 2015. children remain vulnerable to death and disability caused A half-century ago, revolutionary breakthroughs in science essential importance of sustained political will, elim- Fifty-five of the world’s 99 afected countries are on track by malaria is simply unacceptable. and medicine convinced many world leaders that no infec- ination-focused implementation, ongoing invest- to cut their malaria incidence by at least 75 percent before tious disease was equal to the power of human innovation, ment in R&D, and new approaches to financing. the end of 2015, with about 30 of those countries aiming to Today, we have an opportunity to achieve something that and in 1955 the WHA adopted an ambitious resolution complete elimination by 2025.8 ,9 was once thought impossible. With the right combination in support of malaria eradication.13 Elimination cam- It also seeks to distinguish between 20th-century of political will, strategic rigor, technical innovation, paigns were soon launched across Europe, Asia, and approaches to eradication—with their almost exclusive These results demonstrate what leaders can achieve and focused investment, we can end malaria forever. the Americas that sprayed millions of households with reliance on large-scale campaigns wholly financed when they set ambitious goals, and that the will to take The research and development (R&D) pipeline for new insecticide and administered treatment where needed.14 by donors and based on one or two interventions and action against malaria has never been stronger. In diagnostics, treatments, and vaccines has never looked strategies—and 21st-century approaches to eradica- November 2014, 18 Asian-Pacific heads of state pledged better—and malaria eradication could save an estimated This efort succeeded in eliminating malaria from more tion, whose success will be determined by commu- to eliminate malaria from their region by 2030—and in 11 million lives and unlock an estimated $2 trillion in than two dozen countries, many of them in higher-trans- nity engagement, country ownership, and the degree January 2015, 49 African heads of state endorsed the economic benefits over the next 25 years.12 mission settings in the Caribbean and Asia. At the global to which they are successfully integrated into and desire to eliminate malaria south of the Sahara by 2030.10 level, overconfidence in the power of insecticides and financed as part of primary health care systems. This means that the leaders of nearly every remaining To achieve that end, we must have an open and honest drugs led to underinvestment in R&D for new tools afected country have pledged to end malaria transmission conversation about what it will take to achieve eradication. and technologies. And at the country level, the political within their borders before the middle of this century. The key participants in this dialogue must include afected- commitment to elimination waned as malaria cases ap- The challenge is that terrible inequities remain. As many country and regional leaders, global policymakers, leading proached zero. As a result, the World Health Organi- If we are serious about achieving as one billion people are currently infected with the donors, heads of international agencies, civil society zation (WHO) ofcially suspended—but did not formally the vision of a malaria-free world, 15 organizations, scientific researchers, and others who end—the global malaria eradication program in 1968. we need to start talking about 7 United Nations, The Millennium Development Goals Report 2015 (New will be essential to planning, organizing, financing, and Given this history, a healthy measure of caution is York: UN, 2015) . implementing eradication eforts. what it will take and how we get 8 World Health Organization, World Malaria Report 2014 (Geneva: WHO, there. 2014). 13 Centers for Disease Control and Prevention, ‘The History of Malaria, an Let the conversation begin. Ancient Disease’. November 9, 2012. Web. 9 Kaiser Family Foundation, The U.S. Government and Global Malaria (Menlo 11 World Health Organization, World Malaria Report 2014 (Geneva: WHO, 14 Roll Back Malaria, Eliminating Malaria: Learning from the Past, Looking Park: KFF, 2015). 2014). Ahead (Geneva: WHO, 2011), 10 Asia Pacific Leaders Malaria Alliance Secretariat, ‘East Asia Summit 12 For all original analysis, we provided the following citation: Original 15 Roll Back Malaria (2011). Adopts Unprecedented Regional Malaria Goal’. November 14, 2014. Web. financial modeling for Aspiration to Action. For details, see “Methods” section in online appendix. 17 | From Aspiration to Action From Aspiration to Action | 18

What will it take to end malaria? The fight against malaria over the past 15 years represents one of the greatest success stories in the history of public health.

Photo by Maggie Hallahan / Malaria No More 19 | From Aspiration to Action From Aspiration to Action | 20

millions of people infected

700M 700000000 2015 2020 2025 2030 2035 2040 600000000 600M 500000000 500M 400000000 400M 300000000 300M 200000000 200M 100000000 100M 0 0

To build the case for eradication and demonstrate its feasibility, we must achieve these 2020 morbidity 2015-2020 and mortality targets—and go further, by making substantial progress in the following areas over the next five years: THE FIRST FIVE YEARS: A Renewed Commitment Increase the resources available to combat malaria. options including pediatric formulations, drugs to ad- Over the next five years, the global malaria community dress resistance, single encounter cures, and lon- to Eradication must mobilize new resources to fuel ambitious coun- ger-acting treatments and transmission-blocking drugs. The fight against malaria over the past 15 years try plans. This will require securing new commitments represents one of the greatest success stories in the from afected-country governments and regional fund- Conduct a technical debate on how to achieve history of public health. We must sustain that ing bodies, expanding transitional finance opportuni- eradication. A comprehensive efort, led by the WHO momentum by reducing malaria cases and deaths to ties, and sustaining ofcial development assistance Global Malaria Program, will help develop technical and 2,235,045,491 the lowest possible levels in the next five years. This (ODA) support provided by leading donor countries. normative guidance for achieving global malaria erad- infected people will set the stage for elimination in many countries ication within a set timeframe. The debate can build and ensure continued political support from afected Pilot new sub-regional elimination strategies to on the foundation laid by the WHO’s Global Technical countries and donor countries alike. demonstrate the feasibility of eradication. An initial Strategy for Malaria, 2016-2030, recently ratified by set of countries in the Asia-Pacific region, the Amer- the World Health Assembly (WHA), by applying a delib- The World Health Organization’s (WHO) Global icas, and sub-Saharan Africa will aim to eliminate erate timeframe to the strategy’s ambitious goals for a Technical Strategy calls for at least a 40 percent malaria by 2020, inspiring and igniting action within malaria-free world. reduction in malaria-related mortality and morbidity their regions. These early wins will reinforce political between 2015 and 2020.16 commitment, just as this learning period will provide Secure a WHA declaration on malaria eradication. critical lessons for how individual nations and sub-re- If key milestones have been met in the above areas, gional clusters of countries can adopt new strategies the WHO should develop and endorse a plan to pursue to accelerate the pace and efciency of elimination. and complete the work of malaria eradication by mid-century. This plan should secure the highest-

16 World Health Organization, Global Technical Strategy for Malaria 2016- Introduce a first round of new tools and technologies. possible level of support through a resolution passed 2030 (Geneva: WHO, 2015). Promising new drugs and diagnostics are already in the by the WHA. product development pipeline, increasing treatment 21 || FromFrom AspirationAspiration toto ActionAction From Aspiration to Action | 22

2020-2040 millions of people infected

THE NEXT TWENTY YEARS: 700M The Road to Eradication 600M 2015 2020 2025 2030 2035 2040 A malaria free world will not happen by accident. An enterprise of this scale and complexity requires 500M deliberate strategic planning and strong regional coordination. While no 25-year plan can predict all that may emerge on the path toward global eradication, 400M positive or negative, the following timeline provides a high-level outline of the likely phases that would 300M follow a renewed global commitment by 2020 to achieving a malaria-free world: 200M

100M

0

772,442,678 134,010,007 9,878,568 135,248 infected people infected people infected people infected people

2020-2025 2025-2030 2030-2035 2035-2040 Scaling Up for Elimination: Elimination in Elimination in Achieving Global Eradication:

The number of countries actively pursuing elimination Lower-Transmission Settings: Most High-Transmission Settings: In the final five years, there will likely be three to five would peak in this period, setting the stage for region- Elimination in the Americas and the Asia-Pacific region To reduce the number of affected countries to a countries that remain afected and present tough chal- al elimination in the Americas, the Asia-Pacific region, could be completed by 2030, leaving sub-Saharan handful and set the stage for global eradica- lenges to global eradication, such as a limited health- and lower-transmission countries in sub-Saharan Af- Africa’s high-transmission areas as the only tion, the majority of African countries will need care infrastructure and social and political instability. rica by 2030. These eforts could accelerate with the remaining afected region. To prepare tropical Africa to achieve elimination by 2035. The introduction Sustaining commitment at this stage is important to broad availability of new tools that include single-dose for elimination in the decade that follows, the WHO’s of game-changing innovations—including vaccines ensure that national caseloads are reduced to zero and curative treatments and improved diagnostics capa- Global Technical Strategy target of a 90-percent re- that interrupt transmission and novel mosquito resurgence is prevented. Foreign assistance to the re- ble of detecting asymptomatic infections. In this peri- duction in malaria morbidity and mortality must be control strategies—could have a substantial impact in maining afected countries will be essential—possibly od, current donors will need to sustain their funding achieved by 2030. accelerating this phase. through a dedicated “last-mile fund”—to ensure that to maintain the unprecedented low levels of malaria the resources required to complete eradication are deaths, and afected countries will need to significantly available in the final phase. increase their funding to accelerate progress. 23 | From Apiration to Action FromFrom Aspiration Aspiration to to Action Action | | 24 17

Exhibit 1

NEW STRATEGIES NEW TOOLS NEW FINANCING

Global eforts strengthened to reduce New drugs introduced to acceler- Sustain U.S. and U.K. government malaria cases and deaths by the ate the elimination of Plasmodium commitments to malaria while Global Technical Strategy target of at falciparum and Plasmodium seeking new bilateral commitments least 40% between 2015 and 2020 vivax malaria from new and existing donors

Detailed elimination roadmaps Novel vector-control methods devel- Ensure successful Global Fund developed and endorsed by oped to reduce malaria transmis- Replenishments in 2016 and 2019, regions (Asia, Africa, Americas) sion within households and outdoor with strengthened requirements and transmission settings incentives for afected-country and regional counterpart financing

New strategies piloted to reach First round of new tools and Expand afected-country access or exceed Global Technical technologies introduced (including to long-term loans for malaria Strategy target of at least 10 highly sensitive RDT, complete-cure eradication through global and countries eliminating malaria treatments, and innovative vector regional development banks by 2020 control methods) (Asia, Africa, Americas)

Operational research conducted Strengthened use of data to inform Demonstrate the potential of transi- to inform optimal use of new tools optimal control and elimination tional financing and novel financing and implementation approaches strategies approaches to stimulate increased domestic investment in malaria

WHO leads technical debate Regulatory review streamlined Secure new or renewed commit- on how to achieve elimination, and new tools and technologies ments to malaria from institutions including consultation with global piloted to ensure safe and efective including the World Bank, UNITAID, stakeholders deployment and the Global Financing Facility

GOAL GOAL GOAL

Reduce malaria cases and Deliver first wave of new tools Substantially increase and deaths by at least 40% globally and technologies to accelerate diversify global resources available and eliminate in at least 10 elimination and mitigate resistance to combat malaria additional countries 25 | From Aspiration to Action From Aspiration to Action | 26 Exhibit 2 The Shrinking Malaria Map Expanded malaria control and elimination efforts are expected to rapidly reduce the geographic scope and intensity of malaria transmission as the world advances towards malaria elimination goals. The map—derived from an epidemiological model by the Malaria Atlas Project— illustrates one potential pathway to malaria eradication by 2040. As indicated below, malaria elimination is expected to progress unevenly across regions and even within national boundaries due to high variability in weather, mosquito vector populations, transmission intensity, human mobility, and health-system capacity.

by 2020 by 2035

by 2025 by 2040

by 2030

national elimination target dates Global momentum toward malaria eradication is being driven by bold regional commitments and time-bound country plans for elimination. Below is a summary of declared country and regional targets as tracked by the Malaria Elimination Initiative (MEI) at the University of California, San Francisco Global Health Group.

Algeria Botswana China Guatemala Namibia Bangladesh Saudi Arabia South Africa Malaysia Honduras Haiti Cambodia Tajikistan Bhutan Belize Mexico Mayotte* DPR Korea Turkey Costa Rica Nicaragua Sao Tome & Vanuatu Paraguay Dominican Panama Principe* Iran Swaziland Republic Haiti Philippines El Salvador Cape Verde 3-5 high transmission Sri Lanka Republic of Korea Zambia *Mayotte and Sao Tome & Principe do and/or fragile states not have a national or regional goal; Azerbaijan Zanzibar Thailand Nepal Vietnam these dates are the MEI’s projections.

2013 2014 2015 2017 2018 2020 2024 2025 2026 2030 2035 2040 27 | From Aspiration to Action From Aspiration to Action | 28 Impact of Eradication

Return on Investment (ROI) grows over time, thanks to the compounding As a growing number of countries eliminate malaria, overall benefits of almost 11 million cumulative lives saved from malaria. costs decline—but the cost per country eliminating increases Malaria eradication will unlock $2 trillion in total economic benefits. sharply. We must be prepared to cover high per-country costs in the critical end-game period.

10,945,553 LIVES SAVED $687,400,000 COST PER COUNTRY

LIVES SAVED VS ROI NUMBER OF COUNTRIES REMAINING COST PER COUNTRY REMAINING

100 $700M 62.4 12M ROI

$600M 80 10M $500M

60 8M $400M 29.5 ROI

$300M 4M 40 15.7 ROI $200M

8.9 20 ROI 2M $100M 2.9 ROI 0 0 0 0

2015 2020 2025 2030 2035 2040 2015 2020 2025 2030 2035 2040 29 | From Aspiration to Action From Aspiration to Action | 30 The Product Development Pipeline for Malaria

2015-2020 2020-2025 2025-2030 2030-2035 2035-2040

TOOLS & TECHNOLOGY Renewed Commitment Scaling Up for Elimination in Elimination in Most Achieving Global to Eradication Elimination Lower-Transmission High-Transmission Eradication Settings Settings INNOVATIVE VECTOR CONTROL METHODS LLINs with combination chemicals 2016

Innovative Vector Control Methods 2015 – 2025 New chemicals against vectors Anopheline Extinction 2020 – 2025 Technologies post-2025 DIAGNOSTICS

More sensitive diagnostics Non-invasive diagnostics 2016 –2017 2021 – 2025

DRUGS

Increasing treatment Drugs to address Longer-acting treatments options including pediatric resistance and single and transmission-blocking formulations 2015-2018 encounter cures drugs 2019-2025 2019-2025 SURVEILLANCE Mobile phone reporting and tracking 2015 – 2017

New surveillance tools to facilitate data collection/transfer/analysis VACCINE 2015-2020 Transmission interrupting vaccine post 2025

COSTS BY REGION 7B $ Billion 6B

5B AMERICAS 4B ASIA 3B AFRICA R&D 2B 1B

0 2015 2020 2025 2030 2035 2040 31 | From Aspiration to Action From Aspiration to Action | 32 31 | From Aspiration to Action Five key principles will underpin this effort:

1 Find and cure all infections, 4 Take adaptive approaches not just clinical cases to combatting malaria

2 Make surveillance the 5 Integrate malaria backbone of elimination elimination into efective health systems I 3 Tink regionally and act nationally New Strategies

Since 2000, the rapid scale up of proven tools—from long-lasting insecticidal nets (LLINs), to indoor residual sprays (IRS), to artemisinin-based combination therapy (ACTs), to rapid diagnostic tests (RDTs)—has achieved unprecedented success in reducing malaria incidence and mortality. We must expand access to these exist- ing tools, particularly in highly afected countries, while applying new strategies and approaches to accelerate the pace of parasite elimination. 1

Malaria eradication will benefit from key lessons learned from the previous smallpox eradication efort FIND AND CURE ALL INFECTIONS, and from ongoing eforts to eradicate polio and guin- NOT JUST CLINICAL CASES. ea worm. However, this efort will also be diferent in fundamental ways from its predecessors. We must Up to 85 percent of people infected with malaria parasites show no detectable symptoms, but they remain an take an adaptive, problem-solving, implementation important source of disease transmission17, 18. To eliminate and eventually eradicate malaria, we need to reach approach by incorporating new tools and insights as and cure both symptomatic and asymptomatic cases. This will require expanding existing clinical strategies they emerge. and developing new treatment approaches (e.g., screen-and-treat campaigns, targeted treatment campaigns, or seasonal malaria chemo-prevention) that engage entire communities to achieve local elimination. When combined with mosquito control strategies that prevent the reinfection of treated individuals, this approach could be efective in achieving elimination. We must apply new strategies

to accelerate the pace of parasite 17 Teun Bousema, Lucy Okell, Ingrid Felger and Chris Drakeley. “Asymptomatic malaria infections: detectability, transmissibility and public health relevance” (2014). Nature Reviews Microbiology 12, 833–840. elimination. 18 Kim A Lindblade, Laura Steinhardt, Aaron Samuels, S Patrick Kachur, and Laurence Slutsker. “The silent threat: asymptomatic parasitemia and malaria transmission” (2013). Expert Reviews of Anti-Infective Therapy 11, 6: 623-639. 33 | From Aspiration to Action From Aspiration to Action | 34 2

3

MAKE SURVEILLANCE THE BACKBONE OF ELIMINATION

As the WHO’s Global Technical Strategy for Malaria makes clear, efective parasite detection and surveillance are THINK REGIONALLY AND ACT NATIONALLY essential to elimination. This is especially true as countries approach zero cases because the risk of resurgence increases the urgency of timely detection, treatment, and follow up. Surveillance needs to be rigorous, using avail- National boundaries are political constructs that do not able technologies (including mapping, remote sensing, and real-time data analysis) that are supported by robust ofer an efective barrier against the movements of hu- community health worker systems. mans or mosquitoes. This means that countries that have eliminated malaria—or those in the process of Efective surveillance includes: doing so—could sufer from a resurgence, unless they commit to working with their neighbors to develop and The collection of accurate Efective health information Analysis of human mobility Analysis of entomological data implement trans-national surveillance and elimination epidemiological data systems to analyze patterns to understand the on the transmission potential programs. to help countries determine the epidemiological data and make spatial dimensions of malaria of mosquitoes and insecticide- size and location of parasite it available in real time to local transmission and help program resistance patterns to help These programs must be based on data-collection and 4 reservoirs, implement appropriate response teams. managers prevent reintroduction countries design appropriate interventions, and forecast in cleared areas. See Exhibit 3 control eforts. data-sharing agreements among blocks of nations that commodity demand. are linked by shared ecological, epidemiological, and economic features that enable cross-border parasite transmission. By thinking regionally, designated coun- TAKE ADAPTIVE APPROACHES TO Exhibit 3 try blocks can map both major infection “hot spots” COMBATTING MALARIA A new understanding of parasite mobility is transforming how we track and combat malaria. Combining par- within their malaria ecosystems, and the human mi- asite positivity data with modeling of human movement patterns based on census data and mobile phone call gration patterns that export parasites from hot spots In the 1950s and 1960s, the global malaria eradication data records (CDRs) produces a map of parasite mobility within and between borders. Applied to regional to other areas. This will allow individual countries to program relied on a single intervention to interrupt blocks like Southern Africa (shown here), this enables malaria interventions to be coordinated for maximum concentrate their elimination eforts on high-preva- parasite transmission and accelerate elimination– impact and efciency. lence areas and work collaboratively with neighboring spraying households with Insecticide. This approach nations to implement public health interventions that was efective in many low-transmission settings, but it 1. population movement 2. parasite positivity 3. parasite movement focus diagnosis, treatment, and prevention on those was inadequate to the rapidly evolving biological chal- most at risk of acquiring or transmitting malaria (e.g., lenges posed by other settings. In the 1970s, insecticide test-and-treat programs for labor migrants who work and drug resistance emerged but governments did not in high-prevalence areas). invest in the development of follow-on drugs and vector control methods. Countries that share a malaria ecosystem can also share best practices and lessons learned from oth- By contrast, elimination strategies in the 21st century er national elimination programs. For the most part, will operate with a strong respect for evolutionary prin- malaria elimination is a national efort, driven by coun- ciples. They will use operational research to identify the try-level political leadership, financing, and public most efcient and efective approaches to deploy new health systems, but the pace and success of elimina- tools and strategies as they emerge. And they ultimate- tion in many countries will ultimately rely on efective ly will advance through a multi-pronged efort that in- Analyses and images are an output of the WorldPop project trans-national collaboration. See Exhibit 4 for informa- cludes investments in better methods of surveillance, (www.worldpop.org) and the Flowminder Foundation (www.flowminder. tion on current regional elimination eforts. prevention, diagnosis, and treatment. org), and were produced by Andy Tatem, Nick Ruktanonchai, Alessandro Sorichetta, Natalia Tejedor, Emanuele Strano, and Matheus Viana. 35 | From Aspiration to Action From Aspiration to Action | 36

5

INTEGRATE MALARIA ELIMINATION INTO EFFECTIVE HEALTH SYSTEMS

The 2014 Ebola epidemic in Africa has underscored at times, ultimately malaria elimination eforts must the central role of efective health systems in disease be deeply integrated into efective health systems to surveillance, treatment, and prevention—and strong be sustainable and cost-efective. eforts are underway with support from the WHO, the G7, the U.S. Centers for Disease Control and Prevention, We are already on the way to a malaria-free world. the African Union, and others to revitalize integrated At the beginning of the 20th century, malaria afected health service delivery and surveillance in developing nearly every nation on earth. Since then, more countries. than half of the member states of the United Nations have successfully eliminated the malaria parasite Efforts to combat malaria both contribute to and within their borders, and dozens of countries are benefit from strengthened health systems—specifically, scheduled to complete elimination in the next decade. primary healthcare at the community level. The same Eradication will not be achieved through a single, frontline health workers who diagnose and treat top-down global efort but through national and sub- malaria deliver other essential care, and will also be regional commitments to elimination led by afected key for case detection as malaria burden decreases. countries, with support from regional and international Revitalized, integrated health systems will include donor governments and the private sector. Many of the scale up of efective national and regional disease these regional elimination eforts are already taking surveillance programs, which will be essential to the shape. Ultimately, this is where the eradication efort detection and treatment of malaria in many afected will be won. countries. Although vertical campaigns will be required

Eradication will not be achieved through a single, top-down global effort but through national and sub- regional commitments to elimination led by affected countries, with support from regional and international donor governments and the private sector. 37 || FromFrom AspirationAspiration toto ActionAction From Aspiration to Action | 38

Exhibit 4 ENDING MALARIA IN SOUTHEAST ASIA Three Major No regional elimination efort is more critical over the next five years than the successful elimination of P. falciparum malaria from the five nations of Southeast Asia (Cambodia, Laos, Myanmar, Thailand, and Vietnam) that, together Elimination Efforts with Yunnan Province in China, make up the Greater Mekong Sub-region (GMS). While the malaria disease burden has been reduced significantly across the GMS, important drug resistance “hot spots” have emerged in forested Three major regional elimination eforts are currently border areas. These hot spots pose a direct threat to the success of global elimination eforts. If the spread of underway in Southeast Asia, Hispaniola, and sub-Saharan drug-resistant parasites is not checked through the elimination of all P. f a l c i p a r u m parasites in the region, it is Africa, and they can achieve critical milestones by 2020 likely that (MDR) multi-drug resistant malaria will spread worldwide, increasing the cost and reducing the efcacy with support from regional and global stakeholders: of malaria elimination eforts everywhere. With support from regional governments, the Global Fund, Australia’s DFAT, the U.S. President’s Malaria Initiative, UK AID, and the WHO, regional elimination eforts have been launched with the goal of completion by 2020.

ENDING MALARIA IN NORTH AMERICA

Haiti and the Dominican Republic (collectively the Island of Hispaniola) remain the only two countries afected by malaria among the 28 independent nations and dependent territories of the Caribbean region. In February 2015, the Haiti Malaria Elimination Consortium (HaMEC) was launched with the goal of eliminating malaria from the Island of Hispaniola by 2020. This innovative partnership brings together committed grassroots health workers from Haiti and the Dominican Republic with global experts in public MALARIA ELIMINATION IN SOUTHERN AFRICA health, led by the U.S. Centers for Disease Control and Prevention (CDC) and the CDC Foundation. If Sub-Saharan Africa accounts for more than 90 percent successful, HaMEC will end malaria transmission and of the global burden of malaria, and no nation south of reintroduction across the Caribbean and pay for itself by the Sahara has succeeded in eliminating the disease. strengthening the reputation of Haiti and the Dominican Thanks to leadership from the Southern African Republic with international tourists. A parallel efort to Development Community, that is about to change. SADC eliminate malaria from Central America is underway members have formed the Elimination Eight Initiative with financing and technical support from the Global (E8) with the goal of eliminating malaria from four of Fund and the Pan-American Health Organization, which its member states by 2020 (Botswana, Namibia, South means that we could witness the final elimination of Africa, and Swaziland) and from the remaining four malaria from North America within a decade. member states by 2025 (Angola, Mozambique, Zambia, and Zimbabwe). The E8 initiative will be led by a trans- national coordinating committee, and each E8 country has adopted a rigorous elimination scorecard that will measure national progress toward achieving efective surveillance, treatment, and prevention targets.

3939 || FromFrom AspirationAspiration toto ActionAction From Aspiration to Action | 40

The malaria product development pipeline has never looked better, promising a number of transformative new products that will accelerate New malaria elimination efforts. Tools

Twenty-five years ago, it would have been hard to predict the strides that the world has now made in developing better tools to fight malaria. In 1990, front-line malaria treatments were failing, artemisinin-based combination therapies (ACTs) were unavailable, and low-cost rapid diagnostic tests and long-last- ing insecticidal nets (LLINs) were still yet on the horizon. But then a new wave of afordable treatments and prevention tools emerged to reassert the power of human innovation and unlock investment in malaria in the 1990s and 2000s.

The outcome has been a robust pipeline of potential game- changing products. The malaria product development pipeline has never looked better. The table that follows provides a sum- mary of the diagnosis, treatment, and prevention interventions that could be available in the near future. While timelines for product availability may by delayed by several factors—includ- ing clinical trials and funding for procurement—the number of high-impact interventions that could be available by 2025 is impressive and perhaps unrivaled in the field of infectious disease R&D. It is also feasible, given enough political will and focused investment.

We need next-generation tools and strategies not only to accel- erate elimination, but also to mitigate the challenges posed by multi-drug resistant (MDR) parasites and insecticide-resistant mosquitoes. As many in the global malaria community know, the growth of MDR malaria in the Greater Mekong Subregion currently poses a threat to treatment around the world, and the expansion of pyrethroid-resistant mosquitoes across sub-Saha- ran Africa likewise threatens the efectiveness of LLINs.

Photo by Esther Havens / Malaria No More 41 | From Aspiration to Action From Aspiration to Action | 42

1

NEAR-TERM INNOVATIONS

There are a number of potentially transformative products that could be available within 10 years:

COMPLETE-CURE TREATMENTS INNOVATIVE VECTOR CONTROL METHODS Candidate treatments for P. f a l c i p a r u m and P. v i va x m a - In sub-Saharan Africa, where indoor biting at night laria that could deliver a single-dose, complete cure is the leading cause of malaria transmission, insecti- for malaria are in advanced clinical trials and could be cide-treated wall liners, insecticide-embedded paints, available by 2020. If successful, these treatments would eave tubes, and other innovations could strengthen be capable of clearing all malaria parasites through vector control by closing “residual transmission gaps” a single administration of just one or two drug that occur when people are out of bed at night or in tablets—a clear advantage over ACTs which are efective the early morning. The deployment of next-genera- in clearing the body of asexual-stage parasites that are tion LLINs with new combination insecticides could responsible for transmission but are not efective in also overcome pyrethroid resistance and extend net eliminating sexual-stage parasites. The real danger efectiveness from three to five years. In Asia, where with multiple doses is not just that patients remain outdoor transmission is a leading cause of malaria infected if they stop treatment when they feel better; it’s infection, novel vector control measures designed to also that a failure to complete a full course of medica- protect rural workers in the artisanal mining, forestry, tion contributes to the development of MDR malaria. and agricultural sectors could play a major role in en- 2 suring the safety of Southeast Asia’s sizable migrant Photo by Esther Havens / Malaria No More worker populations from infection, while also helping to prevent the re-importation of malaria into areas that have eliminated the parasite when workers return TRANSFORMATIVE END-GAME PRODUCTS to their families. Potential innovations could include insecticide-embedded clothing and novel repellents. Beyond the near-term innovations described above, there are two R&D eforts in early phase discovery and development: that could deliver game-changing malaria elimination tools between 2025 and 2035.

HIGHLY SENSITIVE DIAGNOSTICS VACCINES THAT INTERRUPT MALARIA TRANSMISSION NOVEL MOSQUITO CONTROL STRATEGIES Malaria detection has been revolutionized by the devel- Highly efcacious and long duration vaccines that While there are more than 3,400 mosquito species opment of RDTs—cheap yet accurate point-of-care tests either prevent parasites from proliferating in the blood- worldwide, nearly all malaria parasites are transmit- that help health workers distinguish malaria infection stream or interrupt the parasite transmission between ted by a few dozen species in the Anopheles genus. from other causes of fever. Additionally, new, highly sen- mosquitoes and humans could accelerate eforts to Researchers are seeking to induce genetic changes sitive tests are in development that could detect para- prevent parasite transmission and reintroduction. that could cause sustained reductions in mosquito site infection in people who are infected but asymptom- populations—and could lessen the costs and environ- atic. These tests could be available for use by 2020. mental impact of malaria elimination eforts by limit- ing insecticide use. 43 || FromFrom AspirationAspiration toto ActionAction From Aspiration to Action | 44

III Affected-country and regional financing will have to increase significantly to achieve New the ambitious elimination targets being set Financing by countries.

Between 2000 and 2013, annual global investment in malaria grew 2,000 percent—from $130 million to $2.7 billion per year. This increase fueled an unprecedented scale up of malaria interventions, primarily the delivery of long-lasting insecticidal nets (LLINs) and artemisinin- based combination therapy (ACTs). Most of the funding came from Ofcial Development Assistance (ODA) Photo by Esther Havens / Malaria No More provided directly by the U.S. and U.K. governments or through the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund), the World Bank, and UNITAID. collection, sophisticated country and regional advocacy Momentum toward elimination at the regional and eforts will be essential to ensure that countries dedicate sub-regional levels will help drive resource mobili- To put the world on the path to eradication, malaria a portion of increased revenues to malaria, among other zation eforts. Groups of countries that define com- funding will need to double between 2015 and 2025.19 critical health priorities.20 Finally, as economic growth mon elimination targets and timelines will be able to Global ODA alone, however, is not anticipated to causes afected countries to become ineligible for certain make a compelling case for investment within domes- grow at rates that will meet the cost requirements of forms of financing, the transition from ODA must be tic health budgets, among their neighbors, and with malaria eradication. Therefore, affected country and anticipated and carefully managed, as recent examples other regional and global partners—particularly to regional financing will have to increase significantly from the Global Fund and the Gavi Alliance illustrate. the extent that they can demonstrate that elimination to achieve the ambitious elimination targets being contributes to regional health security and econom- set by countries and regions. The first decade, in particular, constitutes a critical ic growth. Current elimination eforts in sub-Saharan ramp-up period, as afected countries scale their com- Africa, the Greater Mekong Sub-region (GMS), and the The International Monetary Fund (IMF) projects that mitments and as regional funding is introduced. ODA Caribbean have already demonstrated the ability to at- many countries in Africa, the Americas, and Asia will and transitional financing mechanisms will play vital tract funding on a multi-country basis. Other groups of double or triple the size of their economies in the next roles in sustaining coverage of life-saving tools, fill- countries working together toward elimination should decade, buoyed by annual GDP growth rates of 3-10 ing gaps, and smoothing the transition to increased build on this approach by fashioning compelling cases percent. This should position afected countries and domestic financing. Global and regional development for investment aimed at regional and global donors. regions to provide complementary funding for malaria banks will play a key role in facilitating the scale up of interventions or, in select cases, entirely finance malaria domestic investment by providing concessionary loans While securing funding for elimination over the next de- elimination within their borders. But economic growth and guarantees and by backing development bonds and cade will be challenging, consideration must also be giv- alone does not guarantee investment; more efective other financing instruments that will allow countries to en to financing the critical malaria “end game” between revenue collection programs are needed to help countries access afordable capital and shift costs into the future. 2030 and 2040, when political will is most likely to falter generate additional health funding. To support revenue and when the risk of resurgence will be the highest. It is 20 The value of investing in malaria elimination will need to be weighed against other national health and development priorities, and it will be expected that international donors will play a lead role important for advocates to underscore the secondary benefits that malaria in sustaining this final phase of eradication. 19 Original financial modeling for Aspiration to Action. For details, see elimination delivers in regard to health system strengthening, educational “Methods” section in online appendix. attainment, and economic productivity. 45 | From Aspiration to Action From Aspiration to Action | 46

THE COSTS OF ERADICATION FINANCING SOURCES Specific approaches to financing malaria elimination will vary by region. In the Americas and the Asia-Pacific Any costing of a 25-year eradication effort is As countries aggressively expand control eforts region, funding will need to be mobilized principally through domestic and regional financing. In many African speculative and involves uncertainties that increase and introduce new strategies and tools to pursue countries, it is likely that ofcial development assistance (ODA) will continue to play an important role even as over time. Nonetheless, initial modeling suggests elimination, malaria funding will need to double domestic and regional contributions increase. that the costs of eradicating malaria could be $90- between 2015 and 2025, when annual costs peak at $120 billion between 2015 and 2040 (see Exhibit 5).21 over $6 billion. Costs are then expected to decline potential financing sources globally International & Exhibit 6 This compares to an estimated $2 trillion in economic after 2025, as clusters of countries (and eventually Regional ODA benefits between 2015 and 2040 from productivity entire regions) achieve elimination. However, while $ Billion Gap gains and health savings. overall costs are expected to decline over time as Domestic 6.5 more countries become malaria-free, the cost per Two trends should mitigate long-term growth in country will substantially increase once eradication 5.5 Private Foundation/ Donor costs. First, advances in surveillance, data analysis, reaches an end-game phase—which will almost 4.5 and modeling should improve each country’s ability certainly need to be financed by international donors. Private Insurance to focus interventions in specific areas and avert the Between 2030-2040, 65 percent of the costs are 3.5 and Out of Pocket high costs associated with indefinitely maintaining expected to be funded by ODA. 2.5 Industry universal coverage strategies. Second, urbanization trends in afected countries could reduce the number 1.5 of people at risk of malaria and allow governments to deliver detection, treatment, and prevention more .5 cost-efectively. 0 2015 2020 2025 2030 2035 2040 potential cost by region Exhibit 5 Africa Asia Americas R&D 1

$ Billion ODA 6.5 To date, ODA has provided the vast majority of malaria structuring their contributions in ways that incentivize 6 funding. In 2013, it represented 82 percent of the $2.7 counterpart financing from afected countries and re- billion invested annually in malaria eforts. The Global ward progress toward elimination. This outcomes-ori- 5.5 Fund is the single largest source of ODA, and bilateral ented approach is already being integrated into the new 5 4.5 funding through the U.S. government (the President’s funding model that the Global Fund adopted in 2013. Malaria Initiative) and the U.K. government (the Depart- Donors will also need to sustain eforts where domestic 4 3.5 ment for International Development) also has been criti- capacity cannot meet eradication financing needs. cal. The World Bank has historically played an important 3 role in ODA for malaria, and it will be critical to cur- Traditional donor governments provide the majority 2.5 rent eforts for it to resume that role.22 Current donors of funding for R&D to develop new tools to fight ma- 2 also will need to grow their ODA commitments,23 while laria. Currently, 50 percent of R&D is funded by gov- 1.5 1 21 Further details on the costing methods are provided in the Methods 22 New mechanisms, such as the Global Financing Facility (GFF), may .5 section in the online appendix. present a vehicle for continued World Bank investment. 0 23 For the purposes of this model, it is assumed that malaria contributions from the U.S. and U.K. governments, as well as the Global Fund, will grow 2015 2020 2025 2030 2035 2040 through 2030 at a rate equivalent to the average growth rates of past years, between 2010 and 2014. 47 | From Aspiration to Action From Aspiration to Action | 48 ernments, with 30 percent provided by private donors integrated into the health care services they provide and the remaining 20 percent by private companies. to workers, dependents, and neighboring communities. Total R&D investment in 2013 was $550 million. To Companies with strong supply and distribution chains in accelerate the development of next-generation inter- rural areas can also support the scale up of donor- and ventions, we estimate investment will need to reach government-financed integrated elimination eforts. $675 million per year.24 Each contributing sector will need to increase its contribution, as ongoing R&D is required to enhance the impact of existing tools and 4 prepare for potential drug and insecticide resistance. REGIONAL FINANCING Opportunities for regional financing are especially strong in the Americas and the Asia-Pacific region, where eco- 2 nomic growth and the regional interests of leading econ- DOMESTIC FINANCING omies—including the containment of drug-resistance in In 2014, domestic financing represented 18 percent of Asia—could encourage wealthy countries to invest in the malaria funding25–and this proportion is growing, but health security of their neighbors. The Islamic Develop- at an insufcient rate to meet the rising costs of elim- ment Bank and the Asian Development Bank have each ination eforts. To finance ambitious regional elimina- developed transitional financing strategies to promote tion targets, afected countries will need to increase domestic investment in essential health and develop- their malaria investments over the next decade by ment needs, and other regional funding bodies should an average of ~170 percent (average annual growth pursue similar approaches. of 10 percent between 2015 and 2025), with the bulk of funding coming from a small number of high-bur- financing sources by region (2015-2040) den countries with rapidly growing economies. Most Exhibit 7 African countries have committed to increasing their health budgets under the Abuja Declaration. To reach the International & Domestic Regional ODA increases required, they will not only need to follow through Private Foundation/ Private Insurance on this pledge but will also need assistance through and Out of Pocket concessionary loans and guarantees. Most afected Donor countries in the Americas and rapidly growing economies AFRICA in Asia could become self-financed in the next decade. $77B 3%

3 financing sources for r&d (2015-2040) 70% 25% 2% PRIVATE SECTOR ASIA-PACIFIC The private sector must continue to be a critical driver $17B 1% Government Private of R&D. Private foundations and the pharmaceutical, Sources Sector health device, and chemical industries have played a critical role in funding the development of new tools R&D 34% 64% 1% and technologies. To accelerate elimination, the mining, $13B forestry, and energy sectors must likewise play a role AMERICAS by ensuring that malaria detection and treatment are $1B 61% 39% 24 Original financial modeling for Aspiration to Action. For further details on the financing methods, see “Methods” section in online appendix. 25 World Health Organization, World Malaria Report 2014 (Geneva: WHO, 2014). 45% 54% 1% 49 | From Aspiration to Action From Aspiration to Action | 50

4 dedicated financing has not already been secured. Transitional Financing and New Sources TAP ADDITIONAL DOMESTIC REVENUE As demonstrated by the fight for polio eradication, Just as innovation is required in the arenas of program implementation and tool development, Since 2001, novel financing has mobilized near- a robust financing strategy will be needed innovation will also play a role in helping countries cover the costs of malaria elimination. ly $100 billion for development in other areas, to sustain efforts. A centralized fund provides and it has grown by about 11 percent per year.28 one mechanism to maintain long-term financing. Here, we identify five tangible innovations that could malaria to complement its new Regional Malaria and Afected countries should explore revenue genera- Such a fund could be established or endowed in the be important to financing malaria elimination and Other Communicable Diseases Trust Fund. Front-load- tion for health by: introducing new taxes on interna- next decade to ensure stable end-game funding. ultimately eradication. Encouraging developments ing investment for elimination in the Greater Mekong tional investment; facilitating debt swaps; floating are already emerging in a number of these areas, yet Sub-region (GMS) between 2015 and 2020 is especial- bonds marketed to diaspora communities, including Over the next five years, we recommend that these significantly more work needs to be done to meet the ly compelling as it could avert the potentially devas- tapping into the remittance market; and developing financing approaches be evaluated, expanded, and future financing needs of malaria eradication. tating future loss of efective treatment there and in domestic-funded instruments, including incentives piloted as required to provide national and sub-regional other parts of the world, making it a true “public good.” to encourage corporate donations, individual philan- elimination eforts with a suite of financing options. The 1 thropic giving, and employee donations. Examples of malaria partnership should evaluate which approaches INCENTIVIZE DOMESTIC CONTRIBUTIONS WITH DONOR MONEY Other instruments—such as health bonds that are novel financing approaches can be found in Appendix 2. are most appropriate for specific countries or sub- Traditional donor institutions are encouraging similar to “green bonds” used to combat climate change regional campaigns. Approaches that shift domestic 5 increased domestic funding by making grants —can help shift domestic financing requirements into financing to the future may be appropriate for rapidly conditional on country counterpart funding. For in- the future while meeting up-front financing needs.26 ANTICIPATE “END-GAME” FINANCING NEEDS growing economies that can expect substantial returns stance, the Global Fund’s new funding model (NFM), While much more work is required to concretely “cap- As with other eradication eforts, the final decade of from malaria elimination and growing revenues. established in 2013, makes 15 percent of a country’s ture benefits,” given that there are clear financial malaria eradication will likely focus elimination eforts Diaspora bonds and debt conversion approaches may potential grants contingent on meeting a “willingness returns for affected countries that invest in malaria on least-developed countries, failed states, and conflict provide new sources of funding for countries with to pay” requirement, which varies by income level. elimination, funding mechanisms should try to esti- zones, where elimination will be costly on a per-case modest growth. Most importantly, demonstrating the Since the NFM was established, domestic financ- mate and capitalize on these returns.27 basis and may require special funding. Given that the scaled impact of these approaches will lend confidence ing for HIV, tuberculosis, and malaria has increased global burden of malaria in the final phase of eradica- to a 2020 decision to move forward with a renewed by an estimated 150 percent. Similarly, the newly 3 tion will be negligible relative to other health priori- World Health Assembly resolution for eradication. established Global Financing Facility (GFF) uses grants REWARD MEASURABLE PROGRESS ties, donor-support for malaria could be challenging if to encourage countries to use World Bank Internation- Additional domestic and donor financing can be gen- al Development Agency (IDA) monies for health. erated through pay-for-performance mechanisms that The significant growth anticipated in affected-country financing (~170 percent by 2025) will not happen reward a country’s ability to meet elimination or other without strong partnership and support from existing donor institutions and regional banks. Below are 2 program targets. The Global Fund’s Meso-America and examples of meaningful efforts that are underway to support the growth of affected-country financing. SHIFT DOMESTIC FINANCING COSTS TO THE FUTURE Hispaniola Regional Initiative provided $10.5 million in The Global Fund’s New Funding Model – The Global Fund’s new funding model sets clear counterpart financing targets for countries based on Concessionary loans make domestic investment at- cash-on-delivery financing to countries that demon- income level and funding history. An additional 15 percent of the Global Fund’s allocation can be accessed by countries if they meet a “willingness tractive by front-loading benefits while allowing coun- strated reduction in malaria cases. It’s a win-win to pay” target for domestic financing. Counterpart financing for HIV, tuberculosis, and malaria has increased by an estimated 150 percent since the tries to pay costs over time. The Islamic Development situation: Countries are encouraged to invest to meet adoption of the new funding model. Bank’s new Lives and Livelihood’s Fund aims to pro- program targets and unlock external funds, and Islamic Development Bank’s (IDB) Lives and Livelihoods Fund – Announced in July 2014, the Lives and Livelihood’s Fund will be a $2.5 billion vide $2.5 billion in grants and religiously sanctioned donors only pay when the desired outcome is achieved. A resource that will deliver a mix of grants and religiously sanctioned loans to IDB member countries for health and development projects. Malaria is loans to member countries—including high-burden similar approach could reward countries that are named as a key priority, and a number of afected countries in Africa and Asia are eligible to apply. malaria countries such as Nigeria and Indonesia—for nearing malaria elimination to assure them that donor Asian Development Bank (ADB) Regional Malaria and Other Communicable Diseases Trust Fund – The ADB Regional Malaria and Other Communica- health and development projects. The Asian Develop- money is in place to finish the job. ble Disease Trust Fund (RMTF) was established in 2013, with the support of partners DFAT, DFID and CIDA. The RMTF aims to scale-up responses to key ment Bank is also exploring concessionary lending for challenges in malaria and other communicable diseases in Asia and the Pacific.

Health Bonds – As part of its Global Financing Facility, the World Bank Group is currently working to construct two of the largest social impact bonds (SIBs) to be issued, both focused on the health sector. One consists of a potential mass replacement of bed nets, where the principal is to be paid back 26 The transportation sector uses various instruments to finance long-term projects. Eurotunnel, the New York Municipal Bond Bank, and the Initiative for the over time by the borrowing government with potential assistance from the Global Fund, and the other for mass deployment of community health workers Integration of Regional Infrastructure in South America used bond structures that frontloaded future financing requirements on the basis of expected future (CHW), which also involves spreading out the up-front CHW scale up costs over time to create more fiscal space for government spending. revenue generation. 27 Health bonds could be strengthened by securing credit enhancement mechanisms (e.g., pooled financing) through multilateral development banks or bilateral agencies, as well as by targeting endowment and sovereign wealth funds as investors. 28 Innovative Financing Initiative, Innovative Financing for Development: Scalable Business Models that Produce Economic, Social, and Environmental Outcomes (Global Development Incubator, 2014). 51 | From Aspiration to Action From Aspiration to Action | 52

Conclusion

Since the turn of the millennium, the world has made unprecedented progress against malaria. Never before have so few people sufered Maintaining a strong political or died from this disease–and never has political commitment been commitment will be impossible so high, nor the pipeline of new technologies looked so good. The unless we can define a clear prospect of a malaria-free world should, therefore, no longer be treated as a distant aspiration. It is a realistic objective that could be end point: eradication achieved within a generation with the right commitment of leadership within a generation. and resources. It will be a hard task, with potential setbacks on the way, including the challenge of insecticide and parasite resistance, funding obstacles, and uncertainties about the right prioritization of tools and implementation approaches. The only way to address these issues is by facing them openly and honestly.

The alternative to eradication—controlling the disease forever without eliminating it—is operationally and politically untenable. Maintaining a strong political commitment will be impossible unless we can define a clear end point: eradication within a generation. And the potential impact is enormous: 11 million lives and $2 trillion dollars of economic impact are at stake.

When a distant goal is identified, there is a tendency for people to lose focus on the present. We cannot aford to lose sight. This document calls for us to change the way we think about the fight against malaria—through new strategies, new tools, and new financing— with an emphasis on meeting or exceeding the near-term targets of the WHO’s Global Technical Strategy and putting the world back on a clear path to eradication.

Everyone has the right to live in a malaria-free world. We can deliver on that aspiration if we take action now to make it a reality.

BILL GATES RAY CHAMBERS Co-chair United Nations Special Envoy for Financing Bill & Melinda the Health Millennium Development Goals Gates Foundation and for Malaria 53 | From Aspiration to Action From Aspiration to Action | 54 Appendix I: REGIONAL APPROACHES TO MALARIA FINANCING

THE AMERICAS THE ASIA-PACIFIC Given the comparatively low disease burden of the In the Asia-Pacific region, momentum is building to Americas and the region’s rapidly emerging economies, support high-level elimination commitments. In No- it is likely that all countries in the Americas, except for vember 2014 at the 9th East Asia Summit, 18 regional Haiti and a small number of countries in Central Ameri- heads of state and government committed to elimi- ca, will have the capacity to cover their elimination costs nating malaria from the Asia-Pacific by 2030. Govern- through domestic financing. International and regional ments in the Greater Mekong Sub-region (GMS) are ofcial development assistance (ODA) may make up an also working collaboratively to accelerate elimination estimated 45 percent of elimination costs, and ODA will to stem the spread of drug-resistant malaria. continue to play a key role in financing between 2015 and 2020. For example, ODA will be the primary source As countries in the area develop, international ODA as of funding for malaria elimination in Haiti, with funding a percentage of public health funding will likely decline. from private foundations also playing a role. In Central Indeed, this trend has been well underway for more America, ODA support will also be needed over the next than two decades. Funding from within the Asia-Pacific decade and could be attracted through coordinated re- region in the form of domestic financing, regional ODA, gional elimination initiatives, such as the Meso-Amer- or regional lending has the potential to replace inter- ica Initiative, which could be co-funded and is already national funding. being supported by the Global Fund.

potential financing sources International & in the americas Regional ODA

Domestic $ Billion Gap .12

.10 Appendices .08 .06 Appendix I | Appendix II .04

.02

0 2015 2020 2025 2030 2035 2040 Source: Original financial modeling for Aspiration to Action. For details, see “Methods” section in online appendix. 55 | From Aspiration to Action From Aspiration to Action | 56

International & loans focused on malaria and other health issues. by 2040.30 Countries that graduate from low-income potential financing sources Regional ODA in asia pacific Australia has also played an important historic role in status may become ineligible for ODA or have difculty Domestic mobilizing health funding for the Asia-Pacific region, securing traditional donor support. In light of this, the $ Billion and it continues to explore opportunities to channel modeling for From Aspiration to Action projects a 50 1.9 funding toward malaria elimination and malaria R&D percent increase for ODA to Africa in the first ten years, through the country’s growing impact-investment with domestic funding growing ~55% over the same Gap model and the Australian Government’s Future Fund. period to meet the cost requirements of control and 1.5 elimination eforts. Increasing domestic financing over AFRICA the next decade will be one of the major challenges Most national economies in sub-Saharan Africa are to putting Africa on a path to malaria elimination. 1.0 projected to grow substantially over the next 25 years, Despite the Abuja declaration, which committed and the region’s GDP is likely to increase nearly 40 per- 40 sub-Saharan African countries to spend at cent between 2015 and 2020.29 If realized, this growth least 15 percent of their national budgets on health, will create expectations among traditional donors that only 8 countries have met their targeted health-care 0.5 sub-Saharan Africa should bear a greater proportion expenditures to date. Most are contributing less than of the costs for health interventions, including malaria 50 percent of their commitment. Yet for most countries, elimination. the cost of eliminating malaria would constitute just a 0 fraction of total health care spending if they were to 2015 2020 2025 2030 2035 2040 According to the World Bank, sub-Saharan Africa will reach the Abuja target. Source: Original financial modeling for Aspiration to Action. For details, see “Methods” section in online appendix. have 26 low-income countries by 2030 (down from 31 today), and this number is expected to decline to 9 Higher-income countries and those experiencing rapid U.K. and the U.S.) to the GMS is currently ~ $50 million growth, such as India, China, Malaysia, and Indonesia, per year. International & will be expected to fund most or all of their national potential financing sources in africa Regional ODA elimination costs over time, but others might need Regional funding could be an important resource for assistance as they scale up domestic commitments. filling this need, as Asia’s leading economies could be Domestic Given the magnitude of the malaria burden in these incentivized by economic and health security concerns $ Billion Gap countries, particularly India and Indonesia, fully and regional geopolitical dynamics to contribute to Private Foundation/ funded elimination programs by these four countries GMS elimination. The global spread of multi-drug 3.6 Donor alone would represent approximately 60 percent of resistance from the GMS could imperil elimination Private Insurance total elimination costs for the Asia-Pacific region. This eforts throughout the Asia-Pacific region, and regional 3.0 and Out of Pocket would translate into about $10 billion in domestic funding could be characterized as a public good for the contributions between 2015 and 2030. region and the world.

2.0 For other countries, international and regional ODA Given that elimination requires coordinated eforts will be required. The World Health Organization (WHO) and generates regional benefits, regional institutions estimates that $3.2 billion to $3.9 billion will be needed such as the Asian Infrastructure Investment Bank between 2015 and 2030 to achieve P. falciparum malaria could support these eforts. Another mechanism is the 1.0 elimination in the GMS. These costs outstrip GMS Regional Malaria and Other Communicable Disease countries’ capacity to finance their own elimination Trust Fund (RMTF), which was established in 2014 plans, and overreach the demonstrated willingness of by the Asian Development Bank (ADB). While direct 0 global donors to support the efort. International ODA contributions to the fund are still being mobilized, ADB 2015 2020 2025 2030 2035 2040 (i.e., ex-Asian funds provided by the Global Fund, the has already prioritized the financing of development Source: Original financial modeling for Aspiration to Action. For details, see “Methods” section in online appendix.

29 World Bank, ‘World Bank Open Data’. 2015. Web. 30 World Bank, ‘World Bank Open Data’. 2015. Web. 57 | From Aspiration to Action From Aspiration to Action | 58

Appendix II: Increasingly, continued ODA commitments are being annually through diaspora bonds. Remittances have been INNOVATIVE FINANCING EXAMPLES tied to growing expectations of domestic financing, used by Israel and India to raise $25 billion and $11 billion as evidenced by the Global Fund’s “willingness respectively in bond funding. Small tarifs on remittances to pay” incentive in its new funding model. Under could also be used to generate national health or malaria this provision, 15 percent of allocated Global Fund funds. resources are contingent on counterpart financing UNLOCK DOMESTIC REVENUES from recipient countries. According to the Global Health bonds and pay-for-performance mechanisms REMITTANCE FUNDS Fund’s initial analysis, the first four waves of concept could unlock significant additional funds. This is especially Israel and India government programs have enabled Israel to raise $25 billion and India to raise $11 note submissions under the new funding model included true given both the expected economic growth projected billion in diaspora bonds. a 150 percent increase in domestic commitments to for Africa and the improvement in national productivity DEBT CONVERSION MECHANISMS Global Fund projects over previous rounds. from reducing malaria disease burden, a leading drain Debt2Health, a trilateral debt swap through the Global Fund that converts country debt into a grant. on worker productivity and health systems. Within the SOLIDARITY TAX In addition to traditional domestic financing sources, malaria community, the Nigeria Bond for replacing long- UNITAID Airline Ticket Levy, a compulsory tax on airline tickets, committed to by nine participat- alternative revenue-generating mechanisms should lasting insecticidal nets (LLINs) is currently being explored ing countries. Fund from this tax have accounted for 65 percent (US $1.2billion) of UNITAID’s total be explored for Africa. These may include tax revenues, by the government of Nigeria, and partners such as the financing resources. tarifs, and insurance schedules, as well as more World Bank and Global Fund illustrate the opportunity for CITIZEN FOCUSED FUNDRAISING INITIATIVE innovative financing approaches. health bond financing. RED is an organization that develops (RED) branded products and services, whose proceeds flow to the Global Fund for investments in HIV/AIDS programs in Africa. For example, additional taxes could come from extractive Finally, advanced market commitments (AMCs) are industries or infrastructure projects. Foreign direct another mechanism that mobilizes funds by linking SHIFT DOMESTIC FINANCING INTO THE FUTURE AND ATTRACT PRIVATE CAPITAL investment (FDI) in Africa has been increasing and in 2014 investment to results. Specifically, AMCs secure quantities was projected to reach $80 billion. Small levies on FDI and price reductions from manufacturers and could be DEBT-RAISING MECHANISMS could help countries secure the resources required for used in Africa to fund the development of vaccines or World Bank Green Bonds raised over $7 billion of funds through fixed income investors since 2008 to support World Bank lending for eligible projects focused on climate change. malaria elimination and other health needs. The floating treatment campaigns. AMCs could help fund the estimated of diaspora bonds should also be considered, given the $8 billion cost of mass testing and treatment campaigns Global Health Investment Fund, a $108 million fund, provides debt funding for the development of significant flow of remittances to Africa; the World Bank between now and a 2040 eradication target. global health products. estimates that $5-10 billion could be raised International Fianance Facility for Immunisation (IFFin) is a longer-term commitment from govern- ments to issue vaccine bonds in the capital markets in order to support GAVI programs. Front-loading of funds leaves ~70 percent of contributions available for use. By 2013 $3.5 billion had been made and $6.3 billion committed.

INVESTMENT FUNDS Global Fund Supports ETF is a financial product based on the Dow Jones Global Fund Index SM.

CREDIT ENHANCEMENTS Pledge Guarantee for Health is a financing partnership that can leverage $100 million in credit through partial guarantees with donor governments (e.g. U.S., Sweden).

ACCELERATE TECHNOLOGY UPTAKE

ADVANCED MARKET COMMITMENTS Pneumococcal Advance Market Commitment (AMC) is an initiative sponsored by GAVI under which $1.5 billion of donor commitments provided to guarantee a low price of vaccines (i.e., 2 billion doses of pneumococcal conjugate vaccine (PVC)). 59 | From Aspiration to Action From Aspiration to Action | 60

Photo by Esther Havens / Malaria No More Acknowledgments A great number of people were consulted in the creation of this document. In particular, we would like to thank the following people for their contributions:

From Aspiration to Action is dedicated to the memory Nahlen and team); the U.S. Centers for Disease Control Analyses and images for the malaria connectivity of the late Alan Magill, who served as Director of the and Prevention (Larry Slutsker); PATH (Paul LeBarre); maps used throughout the document are an output Gates Foundation Malaria Program. This document the Malaria Elimination Initiative of the University of of the WorldPop project (www.worldpop.org) and reflects his vision for a malaria-free world. California, San Francisco (Richard Feachem, Colin the Flowminder Foundation (www.flowminder. Boyle, Allison Phillips, Gretchen Newby); Medicines org), and were produced by Andy Tatem, Nick The Bill & Melinda Gates Foundation (Alan Magill, for Malaria Venture (David Reddy, George Jagoe); The Ruktanonchai, Alessandro Sorichetta, Natalia Bruno Moonen, Chris White, Bryan Callahan, Kieran Global Fund to Fight AIDS, Tuberculosis and Malaria Tejedor, Emanuele Strano, and Matheus Viana. Daly, Julie Walz); the UN Special Envoy’s Ofce (Mark Dybul, Scott Filler); and Gabriel Jaramillo. (Suprotik Basu, Alan Court, Katherine Rockwell, David Analytical support was provided by Alport, Robert Valadez, Jay Winsten); Malaria No More We want to thank Malaria No More for leading the McKinsey & Company. (Martin Edlund, Josh Blumenfeld, Christine McKenna, development of this report and Christine McKenna Jef Doyle); the African Leaders Malaria Alliance for her coordination and project management. Designed by Column Five. (Joy Phumaphi, Melanie Renshaw); the Asian Pacific Leaders Malaria Alliance (Benjamin Rolfe, Bill Parr); We would also like to give special thanks to Simon the World Health Organization (Pedro Alonso); the U.S. Hay, David Smith, and Peter Gething for their pro bono President’s Malaria Initiative (Tim Ziemer, Bernard contributions of analytical and modeling support.